0:01

Next case is a 54 year old man who uh, was admitted

0:04

to the hospital with new onset heart failure, was found

0:07

to have a mildly elevated troponin

0:09

and got an echo to evaluate his heart failure.

0:13

And they thought that he had a left ventricular thrombus.

0:16

So they wanted a cardiac MR to both evaluate potential cause

0:20

of his new heart failure and also look at the thrombus.

0:23

So we're gonna start here with our two chamber view

0:28

and we see that there is really,

0:31

really reduced function in wall mo.

0:34

Um, multiple kind of areas of Kinesis.

0:36

Really the only portion of the heart that seems

0:39

to functioning very well here is the basal anterior segment.

0:42

And then everything else is quite thin and a kinetic.

0:45

So very surprising finding given the relatively minimal

0:50

history that we had here.

0:52

Then looking at his four chamber similar notice

0:56

that already even on this four chamber syn image, we're kind

0:59

of seeing something here that looks kind of mass like

1:04

and we've got a lot of thinning around it.

1:06

It's definitely different than what the

1:08

wall looks like anywhere else.

1:12

So keep an eye on that region as we go through.

1:15

Same thing on the three chamber here.

1:20

It's got a little pulmonary artery catheter kind

1:23

of incidentally noted here in case

1:25

you're wondering what that is.

1:27

And then we'll go move on to our short axis stack.

1:36

And already as we kind of get into the base, you start

1:38

to see anterior segment seems to be moving okay,

1:42

but pretty much everywhere else is thin

1:45

and a kinetic really impacting the

1:50

infra septal and inferolateral segments here at the base.

1:55

And same segments are kind of involved

1:58

as we move our way down, as we get more towards the apex,

2:01

there's much more significant kind

2:03

of circumferential involvement here

2:06

with effectively kinesis of all these segments.

2:10

And then we get to the tree apex

2:12

and you see this large filling defect right here centrally,

2:16

which is sort of what they noted on echo.

2:20

So if I go to our LGE imaging

2:25

and what you can nicely see is in those areas

2:29

where everything was thinned out, we see transmural,

2:32

late gadolinium enhancement.

2:34

You know, this is not a new infarct in this patient.

2:36

The walls are thin, there's transmural enhancement.

2:38

These are non-viable segments.

2:40

Looks like probably RCA territory.

2:42

And then this is gonna be more of a circumferential apex,

2:46

which is probably distal LED territory.

2:48

And then we have this jet black focus here at the apex,

2:53

which we can see in a couple other images.

2:56

And this is a really nice look

2:58

For a kind of mass like thrombus in this location.

3:02

It's right up adjacent to areas of

3:07

infarcted myocardium that aren't moving very well.

3:09

It's a kind of perfect storm for thrombus formation.

3:13

And that is in fact what we see here.

3:17

Often if we know that there's gonna be a thrombus evaluation

3:22

or, or we're suspicious for thrombus,

3:24

that's the particular question.

3:26

Sometimes we will include what's called long TI imaging, uh,

3:30

which can specifically draw out the features of thrombus.

3:33

That's basically

3:34

where you do late gadolinium enhanced imaging.

3:36

And instead of picking the inversion time that optimally

3:40

sort of gnaws the myocardium, you choose a inversion time

3:44

of 500 or 600 milliseconds.

3:45

And what it really functions to do is it allows thrombus

3:49

to show up as really, really obviously black.

3:51

And so there's no kind of question as well whether

3:54

or not a thrombus that wasn't really indicated in

3:56

this particular case.

3:57

'cause it's pretty obvious that this is a thrombus.

3:59

But this is a nice example of myocardial infarction, kind

4:03

of a chronic MI with thrombus complicating things.